HomeMy WebLinkAboutBuilding Plans 1988-11-16
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-I, NO\[ 1 '5 1988~
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VICINITY MAP 6: Envi~;n;.::::;Jeo,\;'
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I ~ USE BLACK INK ONLY
N FOR INSTAL~ER'S USE: Trench Depth ~ 4-" Gravel Depth Below Tile Co ~
( <- ~""1ua<....g,... Tank Capacity tl>OOC.RL. Manufacturer.I.uILC.........o:'t'I1= r;;1>.AIUo~""'.....r.; .A;--
l Measured Distance from Well to Tank - 'From Drainfield - Total Length of Lines~
~ COMPLETE THE FOLLOWING IF A PUMP WAS USED ON THIS INSTALLATION:
I (installer's name) certify that a (Mfg,) (Model No,) Pump
and Mercury Float Switch (Mfg, and No.) have been installed with this sewage installation.
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Permit No. / <j9'-/ Twnshp, _/7 Range ,<:}:3
Standard System)Q, Alternative ~stem O.JSpecify Typ~)
Job Location (Street Address) ,,;?O r(~ ~"..~
Supdivision/Partition #
DETAIL SYSTEM PLOT PLAN AS CONSTRUCTED
Section 3'1.-) 1/ Tax Lot
form c5S-11
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Signatur"
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FOR SANITARIAN'S US~ ONLY: ~ystem Approve'! O~tem DisapproVAd 0 Ne.cgs Correction
COrylMEN]'S;".; .~Lu:o ~~, _ J.At/"" - fJf:~ ~ ~~ -
~LI'~ A 'i~.:.;(:j~--, ...P'AT~a.... ~J/, J~~, .
S' SJ~tem ~ected Oat"
System Capacity ~JlJ gal./day Signature~ _ ~ Date /I_/~ 7~ .
INSTALLATION RECORD & CERTIFICATE OF SATISFACTORY COMPLETION When signl.:rby the County Sanitarian, this certificate, is evi:
dence as per OAS 454.665 of satisfactory completion of a subsurface sewage disposal system at the above location.
To request inspection, return all three (3) copies of this form to: Lane County Environmental Health Services, located in the basement of the
Public Service Building, 125 E. 8th Avenue. Eugene, OR 97401.